Do you remember how, as you were growing up, there was always another kid who would change the rules mid-game to ensure that he won? I do, and it would always make my blood boil. The Centers for Medicare & Medicaid Services can sometimes be like that “always-gotta-win” child.

On Jan. 27, CMS recalculated all Five-Star domains and updated the Special Focus Facility lists. This is not news. Five-Star is updated quarterly. However this past quarter’s update had everyone a little more anxious than usual. Why? Because data that we were told would not count in its calculations, would, in fact, now be included. The rules were changed.

What was not expected to be counted were deficiencies from infection control surveys and MDS data from Q1 and Q2 2020. Previously, CMS indicated these data would not be included in Five-Star calculations, but in early December, a new memorandum reversed that decision and announced that the data was to be included. 

How does CMS rationalize the changing of the rule? In two ways: 1) All facilities had at least one infection control survey and therefore the playing field was leveled, and 2) The MDS data from Q1 and Q2 looked fine.

The truth of the matter is, they were right. 

CMS did change the rules in the middle of the game, but its rationale was “sound-ish.” Aside from that, we also know that there is incredible pressure to “hold nursing homes accountable” for our COVID-19 experience. Calls from advocacy groups, elected officials and media alike to hold nursing homes accountable will not go unanswered. As a byproduct, I suspect the notion of excluding any nursing home data during this period was forced off the table. 

I want to dwell for a moment on the concept of a level playing field and infection control surveys and infection control deficiencies in general. If it were a level playing field, we would not see this disparity in infection control deficiencies across states.

Source: CMS Nursing Home Surveys and Deficiencies Mar 4 to Oct 20 

However, in Five-Star, this is controlled for by comparing facilities within the state to each other, and not the nation. This is true only for the survey domain. However I maintain that this does not go far enough. When you look within a state, things really fall apart. 

For example: In Florida, infection control (IC) deficiencies from March through October 2020 varied considerably by health quality assurance field office (aka: survey district). About 47% of facilities in survey field office 6 received infection control deficiencies, while 2.6% of facilities in district 7 received an IC deficiency. 

A reasonable explanation might be that there are more COVID-19 experiences in district 6 nursing homes compared to 7, but there are not. Facilities in both districts, between March and October, had on average 25 COVID cases. However, as reported above, the survey outcomes between the districts were profoundly different. In fact, there is no correlation between a facility’s COVID prevalence and infection control deficiencies. 

As seen in the table below, in the end, on the macro level, January’s Five-Star release was not a headline above the fold in the Sunday paper, but rather news relegated to the local regional section, right after the report on the virtual community bake sale. But for the 10.1% of facilities that declined in health inspection rating and the 17% that declined in overall rating, these changes have caused great anxiety and, of course, significant practical problems.

 # of Facilities that Gained / Lost Star(s)
Stars Gained / LostOverallOverall % of TotalHealth InspectionHI % of TotalQuality MeasuresQM % of Total
No Change9,93765.7%11,99579.3%8,70557.6%
Source: Zimmet Healthcare Services Group

If we return to the predictable rule-playing, the Quarterly Measure domain will be recalibrated in April 2021. Then the domain will encompass three-quarters of MDS-based measures from the COVID-19 pandemic, not just two as we have now. I suspect the industry will see a decline in many of the QMs and without recalibration, it will appear that the nation’s nursing homes worsened. 

Was yearly recalibration ever contemplated to adjust for downward movement in performance? Doubtful. Will the outside pressures prevail, and recalibration not occur? I am beginning to get that same sinking feeling when that rule-changing bully showed up on the playground. 

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.